Download Formal Psychological Testing in Patients With Paradoxical Vocal

The Laryngoscope
Lippincott Williams & Wilkins
© 2008 The American Laryngological,
Rhinological and Otological Society, Inc.
Formal Psychological Testing in Patients
With Paradoxical Vocal Fold Dysfunction
Omar F. Husein, MD; Tiffany N. Husein, MA; Ricky Gardner, BS; Tendy Chiang, MD;
Douglas G. Larson, BS; Keri Obert, MA; Jennifer Thompson, MA; Micheal D. Trudeau, PhD;
Don M. Dell, PhD; L. Arick Forrest, MD
Objective: The etiology of paradoxical vocal fold
dysfunction (PVFD) has been unclear, but it has long
been hypothesized that there is a significant psychological component. The purpose of this study was to elucidate
the psychological profiles of patients newly diagnosed
with PVFD using psychometrically-sound psychological
assessment instruments.
Study Design: Prospective cohort study of 45
adults newly diagnosed with PVFD at a tertiary university referral center.
Methods: The Minnesota Multiphasic Personality
Inventory (MMPI-2) was administered to test for psychopathology. The Life Experiences Survey (LES) was administered to investigate levels of stress. Demographic,
medical, and social histories were reviewed. MMPI-2 and
LES scores for the PVFD cohort were compared with
scores previously established for normative populations.
Results: The study population included 81% female
and 60% who were age 50 or older. Compared to the
normative population for the MMPI-2, significant differences were noted for both male and female PVFD patients; on average, scores were highly elevated on the
hypochondriasis scale and hysteria scale and less elevated on the depression scale. This pattern was consistent with conversion disorder (P ⬍ .01). In MMPI-2 subset analysis, 18 patients had a classic conversion profile
while 13 others had elevated scores in the three scales of
interest, but not in the classic conversion disorder pattern. Also, 11 patients had normal scores, suggesting no
psychopathology. PVFD patients with a psychological history scored significantly higher on the depression and
anxiety scales than PVFD patients without a psychological history. Patients with a history of asthma or gastroesophageal reflux disease (GERD) achieved significantly
higher scores on the hypochondriasis scale than those
without that medical history. On the LES assessment,
From the Department of Otolaryngology–Head and Neck Surgery
(O.F.H., R.G., T.C., D.G.L., K.O., J.T., M.D.T., L.A.F.), and the Department of Psychology (T.N.H., D.M.D.), The Ohio State University, Columbus, Ohio, U.S.A.
Editor’s Note: This Manuscript was accepted for publication October
18, 2007.
Send correspondence to Omar F. Husein, MD, UC Irvine Department of Otolaryngology, 101 The City Drive South, Building 56, Room 500,
Orange, CA 92868, U.S.A. E-mail: [email protected]
DOI: 10.1097/MLG.0b013e31815ed13a
Laryngoscope 118: April 2008
740
female PVFD patients had significantly lower levels of
positive stress and higher levels of negative stress than the
general population; total levels of stress were not significantly different, however. Male PVFD patients had significantly lower levels of positive, negative, and total stress.
For the entire cohort, asthma (65%), GERD (51%), and a
history of abuse (38%) were common comorbidities.
Conclusions: On average, in both male and female
adults, PVFD is associated with conversion disorder, representing a physical manifestation of underlying psychological difficulty. There also appears to be a subset of
PVFD that is not associated with psychopathology. PVFD
patients with a previous psychological history are prone to
more depressive and anxious symptomatology. Patients
with PVFD and a history of asthma or GERD are more
likely to excessively complain about physical symptoms.
Overall levels of stress are not higher in PVFD patients
compared to a general population. However, females report more negative stress, and both males and females
may have trouble coping with the amount of stress that
they do have. PVFD is more common among women, more
prevalent among older individuals, and can be comorbid
with asthma, GERD, and previous abuse. These results
have implications for treatment— psychotherapy directed
for somatoform and conversion disorders may be added to
traditional speech therapy for increased efficacy.
Key Words: PVCD, paradoxical vocal cord dysfunction, vocal cord dysfunction, airway obstruction, voice, conversion disorder, somatoform disorder, depression, anxiety, stress, abuse, asthma, gastroesophageal reflux disease,
reflux laryngitis.
Laryngoscope, 118:740 –747, 2008
INTRODUCTION
Paradoxical vocal fold dysfunction (PVFD) is a condition involving paroxysmal adduction of the anterior twothirds of the vocal cords during inspiration.1– 4 This episodic glottic obstruction results in distressing shortness of
breath, respiratory stridor, and breathy dysphonia.1– 4
PVFD is most frequently misdiagnosed as asthma since
both conditions are associated with breathing difficulties,
audible respiratory sounds, and attacks, which begin and
end suddenly.2–5 However, patients with PVFD do not respond to antiasthma therapy and most often demonstrate
normal pulmonary function testing.2–5
Husein et al.: Psychological Testing in Patients With Paradoxical Vocal Fold Dysfunction
PVFD can also be misdiagnosed as adductor spasmodic dysphonia (ADSD) or adductor laryngeal breathing
dystonia (ALBD), which are considered neurologic disorders of central motor processing.4,6,7 In ADSD, there are
spasms of the vocal cords that produce an abnormal voice
quality; in ALBD, the vocal cord spasms result in inspiratory stridor and breathing difficulties with normal
voice.4,6,7 Patients with these disorders are highly resistant to speech therapy.4,6,7 They are successfully treated
with botulinum toxin injections which confirms the neurologic etiology.4,6,7 In contrast, PVFD is treated favorably
by speech therapy and does not respond well to botulinum
toxin injections.4,5
To date, the etiology of PVFD has been unclear. Some
have provided a neurologic explanation, suggesting that efferent vagal motor innervation is intermittently activated.7
In this way, the threshold is lowered for stimuli to
produce vocal cord spasm.7 However, no abnormal neurologic testing has ever been reported in PVFD patients.
Several clinical reports have documented an association
with laryngopharyngeal reflux.4,8 Loughlin and Koufman described resolution of PVFD symptoms in 10 patients treated with a daily proton pump inhibitor.8
Another explanation is that PVFD represents a psychological conversion reaction.3,7,9 Conversion disorders
are characterized by alterations in physical functioning
that are rooted in psychological conflict and have no
known physiologic basis.10,11 According to the Diagnostic
and Statistical Manual for Mental Disorders IV (DSM-IV),
a conversion disorder is associated with deficits in voluntary motor or sensory functioning (other than pain) with
symptoms that are not intentionally produced or feigned.10
Also, after appropriate investigation, these symptoms cannot be fully explained by a general medical condition or
from the effects of a substance.10 The explanation that
PVFD is a conversion disorder purports that the abnormal
laryngeal movement serves the purpose of enabling the
patient to avoid confrontation with an unpleasant life situation or emotion (primary gain).9,12 In addition, the PVFD
attacks yield attention and sympathy (secondary gain).9,12
It is interesting that PVFD was originally described
by Patterson in 1974 as Munchausen’s stridor, suggesting
a nonorganic and psychological etiology.13 Leo and
Konaknachi reviewed 171 cases of PVFD from various
other reports that were diagnosed between 1966 and
1998.12 Psychosocial history had been elicited in 49%, and
78% of all patients were female.12 In the review, associated conditions included: conversion disorders (12%), anxiety disorders (11%), histrionic and other personality disorders (6%), family/school conflicts (4%), depression (4%),
psychosomatic disorders (2%), factitious disorders (2%),
and somatization disorders (1%).12 Altman and colleagues
conducted a retrospective review of 10 patients with
PVFD and found that 7 had histories of psychological
disorders.1 These included anxiety, depression, personality disorder (unspecified), and stress disorder.1
To date, despite the numerous reports suggesting a
nonorganic etiology for PVFD, there has been no psychological evaluation of patients using psychometricallysound instruments. This study was designed to elucidate
the psychological profiles of patients newly diagnosed
Laryngoscope 118: April 2008
with PVFD using psychometrically-sound, psychological
assessment instruments. The Minnesota Multiphasic Personality Inventory–2 (MMPI-2) was chosen to assess for
various types of psychopathology. It is the most widely
researched and broadly used personality instrument in
psychology, with scales that assess for depression, anxiety, somatoform disorders, psychosis, etc.10,11 The null
hypothesis was that patients newly diagnosed with PVFD
would not test positive for any psychopathology. We also
investigated stress in PVFD patients using the Life Experiences Survey (LES), a standardized assessment. The
null hypothesis was that PVFD patients would not have
higher levels of stress compared to a standard population.
In addition, a demographic questionnaire was administered and medical histories were reviewed to explore any
relations between PVFD, asthma, and gastroesophageal
reflux disease (GERD).
METHODS
Study Design
This was a prospective cohort study of patients newly diagnosed with PVFD. Patients were administered the entire
MMPI-2, LES, and a demographic questionnaire. The institutional review board approved the study.
Inclusion Criteria
All adult patients diagnosed with PVFD in the Department
of Otolaryngology clinics at the Ohio State University Medical
Center between May 2006 and March 2007 were invited to participate. Videostroboscopy or fiberoptic nasolaryngoscopy was
performed in the clinic setting by one of the speech pathologists
involved in this study. Criteria for diagnosing PVFD were as
follows:
1) absence of gagging or coughing during nasolaryngoscopy,
2) adduction of the vocal cords during inspiration or during both
inspiration and expiration,
3) presence of an open glottic chink during adduction.
If the patient met the diagnosis of PVFD, a flyer was given
inviting that person to participate in the study. All patients were
offered $20 to complete the study.
Exclusion Criteria
Treatment for PVFD consisted of three sessions of speech
therapy involving techniques of biofeedback, stress reduction,
and breathing control—this was termed “laryngeal control therapy.” Any patient who had completed a full course of laryngeal
control therapy (three sessions) was excluded from the study to
avoid the effect of treatment on the results.
Study Conditions
Each patient was tested individually at a time mutually
agreed on by the patient and the study psychologist. Patients
were given a desk and chair in a quiet room in one of the clinics
of the Department of Otolaryngology. Consent forms were completed, and the study psychologist read an introductory statement explaining the tests that would be subsequently administered. The study psychologist then sequentially administered a
demographic questionnaire, the MMPI-2 assessment, and the
LES assessment. On completion, patients were given a debriefing
sheet and offered $20. The debriefing sheet explained the main
purpose of the study and provided contact information.
Husein et al.: Psychological Testing in Patients With Paradoxical Vocal Fold Dysfunction
741
Demographic Questionnaire
A demographic questionnaire was used to assess each participant’s gender, age, race/ethnicity, marital status, education,
vocation, duration of PVFD symptomatology, and previous formal
psychological diagnoses.
Psychological Assessment Instruments
Minnesota Multiphasic Personality Inventory-2
(MMPI-2). The MMPI-2 was used to screen for various types of
psychopathology. There were a total of 567 items on the MMPI-2,
all written in a “true” or “false” format.10 These items were scored
with regard to several validity indices, clinical scales, and additional supplementary scales.10 Only profiles interpreted as valid
were included in the study. The scoring was based on a criterionkey test construction method, meaning that scale membership
was based on selecting items that discriminated a clinical (criterion) group from a group of normals.10,11 All scale scores were
expressed as T-scores, calculated on the basis of normative data.
For each scale on the MMPI-2, the mean T-score was 55
with a standard deviation (SD) of 10.10,11 Scores were considered
elevated at 65 or higher. Elevated scores were examined and the
subscale components that primarily contributed to these elevations were noted. The scores on the supplementary scales were
also examined to elaborate on the personality dynamics and diagnostic status of the patients.11 Some of the scales measured
were as follows:
Scale one (Hs: hypochondriasis) was initially developed on a
group of patients who had many somatic complaints with little or
no organic basis and great concern about their physical
health.10,11 There were 32 items in this scale. Some of the items on
this scale reflected specific complaints or a general preoccupation
with the body. A sample item was, “I do not worry about catching
diseases.”10,11
Scale two (D: depression) was initially developed on psychiatric patients with various forms of depression.10,11 The items in
this scale reflected feelings of discouragement, hopelessness, and
pessimism that characterized clinically depressed individuals.
There were 57 items in this scale. A sample item was, “At times
I think I am no good at all.”10,11
Scale three (Hy: hysteria) was originally constructed on
patients who displayed signs of a motor or sensory disorder for
which no organic basis could be established.10,11 There were 60
items in this scale that reflected specific physical complaints or
related disorders. Many other items involved a denial of problems
in one’s life or a lack of social anxiety. A sample item was, “My
neck spots with red often.”10,11
The A scale (anxiety) had 39 items. High scores on the A
scale reflected anxiety, discomfort, distress, and emotional upset.10,11 High scorers tended to be overcontrolled, inhibited, and
had difficulty making decisions without uncertainty. Additionally, these individuals were prone to becoming easily upset and
conforming in social situations. A sample item was, “I have nightmares every few nights.”10,11
Life Experiences Survey (LES). To assess the relation
between levels of stress and PVFD, the LES was used. The LES
was a 50-item self-report measure that asked respondents to rate
events they experienced in the last year.14 It was separated into
two different sections. Items represented life changes that are
frequently experienced in the general population in a variety of
situations. The assessment was comprised of 47 specific events
plus 3 blank spaces to fill in other events not previously listed.
Sample items included “serious injury or illness of close friend”
and “change of residence.”14
The format of the LES asked respondents to indicate events
that occurred within the previous 12 months.14 Additionally, respondents specified 1) whether they viewed the event as positive
Laryngoscope 118: April 2008
742
or negative, and 2) the perceived impact of the event in their life
at the time of the occurrence. Ratings were based on a seven-point
scale, ranging from extremely negative (–3) to extremely positive
(⫹3). A positive change score was calculated by summing the
ratings of those events designated as positive. A negative change
score was calculated by summing the impact ratings of those
events rated as negative. A total change score was obtained by
adding the positive change score to the absolute value of the
negative change score; this represented the total amount of rated
change.14 All three scores were considered in the study. The
control group for the study was represented by the normative
data provided for this standardized assessment.
Medical and Social History
Clinic charts in the Department of Otolaryngology were
reviewed for each patient. All patients filled out a medical and
voice questionnaire prior to the initial PVFD evaluation. Patients
were determined to have asthma if they had a history of positive
results on pulmonary function testing or equivocal results with
continued symptoms and use of inhalers. They were determined
to have GERD if they had a history of positive endoscopy or pH
probe testing or if they self-reported the condition and used
antacids. No distinction was made between GERD and laryngopharyngeal reflux. One question specifically asked if there was a
history of any verbal, emotional, physical, or sexual abuse. Patients also listed medical diagnoses, surgical history, and current
and past medications. They were determined to have a psychological history if they specifically listed a diagnosis or if they
reported being on medication with psychotropic effects, including
antidepressants and antianxiolytics.
Statistical Analysis
Descriptive statistics were calculated for the data to identify
group means based on gender for each of the constructs studied.
Raw-score and T-score distributions were derived separately for
males and females for the MMPI-2 scales. Positive, negative, and
overall stress scores for the LES were also analyzed separately by
gender. Z-tests were performed to assess significant differences
between the means of the present study and those of the general
population for each of the constructs studied. A two-way univariate analysis of variance (ANOVA) was performed to examine
possible differences among different subgroups of patients on the
MMPI-2 scales of interest: one, two, three, and A. In addition,
Cohen effect size values (d) were calculated for each comparison.
Effect size measured the amount of practical significance in assessing the magnitude of the differences between mean scores of
the present sample and those of the standardization sample. In
assessing the magnitude of the differences in group means, effect
sizes between 0.2 and 0.5 indicated a small to moderate difference, while effect sizes of 0.5 to 0.8 reflected large differences.
RESULTS
At The Ohio State University Medical Center, 62
patients over the age of 18 were diagnosed with PVFD
between May 2006 and March 2007. All patients were
invited to participate in the study. Seven patients expressed interest in completing the study but could not due
to time and travel constraints. Eight patients declined to
participate. Thus, 47 patients completed the study, and all
accepted the $20 payment. Validity scores for the MMPI-2
assessment were interpreted, and 45 of the 47 returned as
valid. For these 45 patients, all MMPI-2, LES, demographic, and medical history results were scored and analyzed. Demographic and history results were summarized in Table I. Overall, 37 (81%) patients were women
Husein et al.: Psychological Testing in Patients With Paradoxical Vocal Fold Dysfunction
TABLE I.
Demographic and History Results of 45 Patients Newly Diagnosed
With Paradoxical Vocal Fold Dysfunction (PVFD).
History of abuse
Average number of ER visits over 12 months
Psychological history
Gastroesophageal reflux disease
Asthma
Age 50 or older
Average age
Women
Men
17 of 45 (38%)
2.4
22 of 45 (49%)
23 of 45 (51%)
29 of 45 (65%)
27 of 45 (60%)
53
37 of 45 (81%)
8 of 45 (19%)
and the average age was 53. The incidences of asthma,
GERD, psychological/psychiatric history, and abuse history were 65%, 51%, 49%, and 38%, respectively.
Mean T-scores, standard deviations, comparison Z-scores
(z), and Cohen effect size values (d) for the four MMPI-2
scales were separated by gender and shown in Tables II
and III. There were significant differences between males
in this study and males in the general population on scales
one, two, and three. Specifically, the mean (M) for the
study group (M ⫽ 68.5, SD ⫽ 17.7) on scale one (Hs) was
significantly higher than the mean for the general population (M ⫽ 55, SD ⫽ 10) (z ⫽ 3.20, P ⬍ .001). The effect size
for this comparison was large (d ⫽ 1.13). The mean for the
study group (M ⫽ 60.5, SD ⫽ 13.8) on scale two (D) was also
significantly higher than the general male population (M ⫽
55, SD ⫽ 10) (z ⫽ 3.20, P ⬍ .001). The effect size for this
comparison was moderate (d ⫽ 0.55). Regarding scale three
(Hy), the mean for the study group (M ⫽ 67.9, SD ⫽ 7.3) was
significantly higher than the general population (M ⫽ 55,
SD ⫽ 10) (z ⫽ 3.20, P ⬍ .001). The effect size for this
comparison was large (d ⫽ 1.29). Conversely, the mean for
the A scale (anxiety) in the study group males (M ⫽ 56.5,
SD ⫽ 20.0) was not significantly higher than the general
population (M ⫽ 55, SD ⫽ 10).
Results for the female cohort (Table III) were parallel
to those found for the male group. Specifically, on scale
one (Hs), the mean for females in the study group (M ⫽
68.1, SD ⫽ 10.6) was significantly higher than the general
population (M ⫽ 55, SD ⫽ 10) (z ⫽ 3.20, P ⬍ .001). The
effect size for this comparison was large (d ⫽ 1.31). The
mean for scale two (D) for the study group females (M ⫽
TABLE II.
Results for Male Paradoxical Vocal Fold Dysfunction (PVFD)
Patients on the MMPI-2 Scales of Interest.
Scale
Scale
Scale
Scale
Scale
one (Hs)
two (D)
three (Hy)
A
Mean
T-Score
Standard
Deviation
Z-Score
Cohen Effect
Size (d)
68.5
60.5
67.9
56.5
16.7
13.8
17.2
19.9
9.06†
3.69†
8.64†
1.01
1.35
0.55
1.29
0.15
Mean ⫽ 55; standard deviation ⫽ 10 for normative group on each scale.
*P ⬍ .01; †P ⬍ .001.
Hs ⫽ hypochondriasis; D ⫽ depression; Hy ⫽ hysteria; A ⫽ anxiety.
Laryngoscope 118: April 2008
TABLE III.
Results for Female Paradoxical Vocal Fold Dysfunction (PVFD)
Patients on the MMPI-2 Scales of Interest.
Scale
Scale
Scale
Scale
Scale
one (Hs)
two (D)
three (Hy)
A
Mean
Standard
Deviation
Z-Score
Cohen Effect
Size (d)
68.1
58.6
65.9
52.2
10.6
12.9
11.2
10.7
8.81†
2.43*
7.29†
⫺1.91
1.31
0.36
1.09
0.28
Mean ⫽ 55; standard deviation ⫽ 10 for normative group on each scale.
*P ⬍ .01; †P⬍ .001.
Hs ⫽ hypochondriasis; D ⫽ depression; Hy ⫽ hysteria; A ⫽ anxiety.
58.6, SD ⫽ 13.0) was also significantly higher than the
mean for the general population (M ⫽ 55, SD ⫽ 10) (z ⫽
2.33, P ⬍ .01). For this comparison, the effect size was
small (d ⫽ 0.36). The mean for the study group for scale
three (M ⫽ 65.9, SD ⫽ 11.3) was significantly higher than
the mean for the general population (M ⫽ 55, SD ⫽ 10)
(z ⫽ 3.20, P ⬍ .001). The effect size for this comparison
was large (d ⫽ 1.09). There were no significant differences
found between the female groups for the A scale. The
mean for the study group (M ⫽ 52.2, SD ⫽ 10.8) was
similar to the values for the general population (M ⫽ 55,
SD ⫽ 10).
According to MMPI-2 criteria, a “conversion-V” profile involves highly elevated scores on the hypochondriasis
(one) and hysteria (three) scales and a less elevated score
on the depression (two) scale.11 This is also known as the
“one, three” or “three, one” profile with a slightly lower
two (the classic “conversion-V”).11 For both the male and
female groups in this study, the overall results on average
were consistent with the conversion-V pattern (Fig. 1).
Although the mean scores for the entire study group
were consistent with a conversion disorder, there were
some differences in subset analysis. Individually, 18 patients had greatly elevated scores on scales one and three
and slightly elevated scores on scale two, consistent with
the classic conversion disorder profile. Five patients had
elevated scores on scales one, two, and three, but the scores
on scales one and three were not both higher than scale two.
Six patients had significantly elevated scores on scale
three (hysteria) but normal scores on all other scales. Two
patients had elevated scores on scale one (hypochondriasis)
70
65
60
55
Scale 1 (Hs)
Scale 2 (D)
Males
Scale 3 (Hy)
Females
Fig. 1. MMPI-2 mean results for paradoxical vocal fold dysfunction
(PVFD) patients showing the “conversion-V” profile.
Husein et al.: Psychological Testing in Patients With Paradoxical Vocal Fold Dysfunction
743
TABLE IV.
Stress Scores for Male Paradoxical Vocal Fold Dysfunction
(PVFD) Patients on the Life Experiences Survey.
Stress
Mean
Standard
Deviation
Z-score
Cohen Effect
Size (d)
Positive score
Negative score
Total score
2.25
2.13
4.38
2.05
2.64
3.74
⫺5.19*
⫺3.89*
⫺6.01*
0.77
0.58
0.89
Mean scores compared with normative group.
*P⬍ .05.
but normal scores on the other scales. One patient had a
greatly elevated scale three score with a slightly elevated
scale two score and a normal scale one score. Overall, these
14 patients demonstrated conversion and/or somatoform features on their MMPI-2 testing, but the classic conversion
disorder profile was not achieved. Two patients had significantly elevated scores on scale two (depression) but normal
scores on all other scales. The remaining 11 patients had
normal scores on all scales of the MMPI-2, suggesting an
absence of any psychopathology.
Comparison means for the Life Experiences Survey
(LES) are displayed in Table IV and Table V. For males,
the mean positive stress score (M ⫽ 2.25, SD ⫽ 2.1) was
significantly lower than the mean reported for the normative population (M ⫽ 6.9, SD ⫽ 6.0) (z ⫽ 2.59, P ⬍ .01). The
effect size for this comparison was large (d ⫽ 0.77). The
mean for negative stress scores for the male study group
(M ⫽ 2.1, SD ⫽ 2.6) was also significantly lower than that
reported for the general population (M ⫽ 4.7, SD ⫽ 4.4)
(z ⫽ 2.59, P ⬍ .01). Regarding total stress scores, the mean
for the study group (M ⫽ 4.4, SD ⫽ 3.7) was also significantly lower than the normative group (M ⫽ 11.53, SD ⫽
8.0) (z ⫽ 2.59, P ⬍ .01). The effect size for this comparison
was large (d ⫽ 0.89).
For females (Table V), the mean positive stress score
(M ⫽ 4.9, SD ⫽ 4.7) was significantly lower than the mean
for the general population (M ⫽ 6.7, SD ⫽ 5.5) (z ⫽ 1.96,
P ⬍ .05). The effect size for this comparison was small (d ⫽
0.33). Conversely, the mean negative stress score in the
study group (M ⫽ 8.5, SD ⫽ 10.7) was significantly higher
than the normative female group (M ⫽ 5.6, SD ⫽ 6.4) (z ⫽
2.59, P ⬍ .01). The effect size for this comparison was
moderate (d ⫽ 0.40). However, the total stress score for
the female study group (M ⫽ 13.0, SD ⫽ 13.1) was not
significantly different from the mean for the general population (M ⫽ 12.4, SD ⫽ 8.8).
TABLE V.
Stress Scores for Female Paradoxical Vocal Fold Dysfunction
(PVFD) Patients on the Life Experiences Survey.
Stress
Mean
Standard
Deviation
Z-score
Cohen Effect
Size (d)
Positive score
Negative score
Total score
4.87
8.19
13.03
4.72
10.71
13.06
⫺2.24†
2.66*
0.52
0.33
0.40
0.08
Mean scores compared with normative group.
*P⬍ .05; †P ⬍ .01.
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744
A two-way analysis of variance (ANOVA) with two
factors was used to perform multiple comparisons between different subgroups of patients on scales one, two,
three, and A of the MMPI-2. Patients were categorized
into one of four nonmutually exclusive groups: 1) medical:
patients with a history of asthma, GERD, or a comorbid
condition of both, 35 (78%); 2) nonmedical: patients with
no history of asthma or GERD, 10 (22%); 3) psychological:
patients with a psychological history, 22 (49%); and 4)
nonpsychological: patients without a psychological history, 23 (51%).
Those in the medical group (M ⫽ 70.6, SD ⫽ 11.9) had
a significantly higher mean on scale one (Hs) than those in
the nonmedical group (M ⫽ 59.9, SD ⫽ 5.9) (F ⫽ 8.328,
P ⬍ .05). There was no main effect for the psychological
subgroup, meaning there were no significant differences
found between those with a psychological history and those
without one. On scale two (D), the mean for the psychological
subgroup (M ⫽ 65.4, SD ⫽ 13.5) was significantly higher
than the mean for the nonpsychological subgroup (M ⫽ 54.7,
SD ⫽ 10.9) (F ⫽ 7.58, P ⬍ .05). There was no main effect for
the medical subgroup, meaning there were no significant
differences found between those patients with a history of
asthma or GERD and those without.
The results of the ANOVA for scale three (Hy) revealed no interaction or main effects between the medical
and psychological subgroups. This signified no significant
differences between patients with a medical history and
those without, and there were no significant differences
between patients with a psychological history and those
without. For the A scale (anxiety), the mean for the psychological subgroup (M ⫽ 59.7, SD ⫽ 12.7) was significantly higher than the mean for the nonpsychological subgroup (M ⫽ 47.9, SD ⫽ 10.1) (F ⫽ 7.31, P ⬍ .05). There was
no main effect for the medical subgroup, meaning there
were no significant differences found between those with a
medical history of asthma or GERD and those without.
The results supported a difference between subgroups
of patients, whereby patients with a medical history of
asthma, GERD, or both had significantly higher scores on
the hypochondriasis scale (Hs) than those that did not have
a medical history of these conditions. Further, patients with
a previous psychological history had significantly higher
scores on the depression (D) and anxiety (A) scales than
patients without a psychological history.
DISCUSSION
PVFD has long been considered a rare diagnosis, but
our experience at The Ohio State University has taught us
that it is not uncommon. Given the large population in
central Ohio, approximately 300 patients are referred
each year for PVFD evaluation. Most of these patients had
been treated for asthma for years, had normal pulmonary
function tests, and were eventually referred by a pulmonary physician. In this group, the average number of
emergency room visits during the previous year for PVFD
symptoms was 2.4. This is a reminder that PVFD can be
disabling and adversely affect quality of life for many
individuals.
To date, the etiology of PVFD has been unclear. Many
series in the literature have demonstrated a high inci-
Husein et al.: Psychological Testing in Patients With Paradoxical Vocal Fold Dysfunction
dence of psychological diagnoses in PVFD patients.1,3,7,9,12
We sought to investigate whether PVFD patients would
demonstrate specific psychopathology on psychometricallysound, psychological assessments. Over a 10-month period, 47 patients with a new diagnosis of PVFD completed
the psychological assessments: 45 of these were interpreted as valid and included in the analysis.
Remarkably, the male and female PVFD patient
groups achieved equivalent average results on each of the
four main MMPI-2 scales evaluated. Compared to the
general population, male and female PVFD patients’
scores were highly elevated on the hypochondriasis scale
(one), mildly elevated on the depression scale (two), highly
elevated on the hysteria scale (three), and not elevated on
the anxiety scale (A). These results for the first three
scales look like a “V” when graphed, and this is known as
the “conversion V” profile. Thus, in both males and females, PVFD appears to be, on average, associated with
conversion disorder (P ⬍ .01). It is known that on the
MMPI-2, the “conversion V” profile is more common
among women and older people than among men and
younger individuals.11 The findings of our study are consistent with this, as 81% of the patients were female. In
addition, 60% were over age 50 and 31% were over age 60.
Since scale two (the scale measuring depressive
symptoms) was significantly elevated in these patients,
the supplementary depression content scale was also
scored. This scale was not significantly elevated, suggesting that PVFD was not associated with a depressive disorder. In addition, both males and females did not score
higher on the anxiety scale than the general population.
According to these results, while patients appear to have
slightly higher depressive symptoms than the general
population, PVFD is not associated with a mood disorder
(depression or anxiety).
Of course there were variations among individual
results on the MMPI-2. While 18 patients individually
achieved the conversion disorder code type, an additional
14 patients demonstrated somatoform and/or conversion
features but did not meet the strict MMPI-2 criteria for
conversion disorder. These individuals may still qualify
for a diagnosis of conversion disorder, but this would require additional testing and evaluation by a psychologist.
Of interest, 11 patients had normal results on the
MMPI-2, suggesting that there is a subset of PVFD patients in whom the disorder is not associated with symptoms of psychopathology. In these patients, PVFD attacks
may be associated with laryngopharyngeal reflux, intermittent bronchospasm, or some other physiologic factor
that has yet to be elucidated.
A conversion disorder is a specific somatoform disorder. Somatoform disorders are psychological difficulties in
which there are symptoms of a physical disorder without
a physical cause.10,15 A conversion disorder is defined as a
deficit in voluntary motor or sensory functioning other
than pain, with symptoms that are not intentionally produced.10 It is thought that a conversion disorder helps
reduce stress by allowing the person to avoid unpleasant
or frightening situations.10,11,15
PVFD seems to be a psychological conversion reaction where the abnormal laryngeal movement may serve
Laryngoscope 118: April 2008
the purpose of avoiding an unpleasant life situation or
emotion (primary gain).9 For example, the respiratory distress and other associated difficulties with speaking may
temporarily resolve the conflict of otherwise expressing
anger or other unpleasant emotional state, as was suggested by Leo and Konakanchi in 1999.12 In addition,
PVFD may give the patient secondary gain through attention and sympathy.9 By analyzing PVFD as a conversion
disorder, it suggests that patients suffering from PVFD do
not consciously produce their symptoms and are generally
unaware of the psychological concerns underlying their
symptoms.9,11 Conversion disorder patients often make
excessive use of denial and projection, and prefer medical
explanations for their symptoms.11,15 We have found that
one of the most difficult aspects is to help PVFD patients
understand that it is a change in behavior and thinking,
rather than a quick medication or surgery, that is most
likely to alleviate the condition.
The symptoms of conversion disorders often have
some particular relevance to the individual patient.15 This
may be the case for PVFD patients as individuals may
have witnessed a traumatic respiratory event, such as a
family member who is ill with asthma. There have also
been reports of PVFD arising in patients with a history of
sexual abuse or forced oral sex—perhaps for these patients, PVFD may represent a more symbolic meaning.3
We found a relatively high abuse history among these
patients, as 38% reported being victims of abuse.
People who suffer from a conversion disorder typically have physical symptoms that increase during times
of stress.11,15 The Life Experiences Survey (LES) was used
to assess the levels of positive, negative, and total stress
affecting these patients over the last 12 months. To maximize optimal well-being, it would be desirable to have
high levels of positive stress and low levels of negative
stress.14 High or low levels of total stress could be associated with optimal well-being, depending on how active one
desires his or her life to be and what ratio of positive to
negative stress one experiences.14
In this study, female PVFD patients had lower levels
of positive stress and higher levels of negative stress than
the general population. In other words, with respect to
relationships and events in the lives of these people, most
things had not gone well during the prior year. The total
level of stress, however, was not significantly different
that the general population. Thus, female PVFD patients
overall do not experience any more stress than others—
however, the stress they do experience is more negative.
Male PVFD patients had lower levels of positive stress,
lower levels of negative stress, and lower levels of total
stress than the general population. Our analysis found
this to be a large difference. This result was surprising,
suggesting that male patients may experience less busy,
eventful, or “chaotic” lives than others. While males and
females with PVFD do not appear to have excessive levels
of stress, their mechanisms to deal with that stress may be
poorly developed or less effective.
Comparisons were made between multiple subgroups
of these patients. Almost half of the patients (49%) had a
psychological or psychiatric history, suggesting that
other psychological diagnoses were also prevalent. In
Husein et al.: Psychological Testing in Patients With Paradoxical Vocal Fold Dysfunction
745
addition, 78% had a history of GERD, asthma, or both,
showing that these medical conditions were common comorbidities with PVFD. Review showed that 44 of 45
patients had carried a diagnosis of asthma at some point
in time. Fifteen of these patients had normal pulmonary
function tests and were eventually determined to not have
asthma—these patients were placed in the nonasthma
group. The remaining 29 patients had a history of positive
or equivocal pulmonary testing and still carried a diagnosis of asthma. In these patients, PVFD appears to coexist
with asthma and may exacerbate the ability to control
asthma symptoms.1,2,4
Subgroup analysis revealed that patients with a medical history of asthma and/or GERD scored higher on the
hypochondriasis scale than the nonmedical group. This
suggests that PVFD patients with the common comorbidities of asthma and GERD complain more about physical
symptoms. It may be that patients with more physical
complaints visit physicians more often, and this naturally
leads to more diagnoses and a more extensive medical
history (PVFD, asthma, GERD). The other significant
finding was that PVFD patients with a psychological history scored higher on the depression and anxiety scales
than patients without a psychological history. This suggests that PVFD patients with a psychological history
demonstrate more abnormal mood characteristics. They
appear to have more depressive and anxious thoughts or
features than other PVFD patients have.
This is the first known study examining PVFD utilizing psychometrically-sound psychological assessment
instruments. Further studies could examine PVFD as a
psychological disorder using a different patient base. For
example, one could investigate this among adolescents to
see if the psychological presentation is similar. The “conversion V” code type is more common among women and
older persons than among men and younger persons, as
we found in our study.11 It will be interesting to see if
pediatric patients diagnosed with PVFD show similar results on the MMPI-A, the form of the Minnesota Multiphasic Personality Inventory normed for adolescents and children. As 38% of patients reported being victims of abuse,
it might be useful to further investigate prior abuse as a
possible contributor to symptoms of PVFD. In the current
study, the type of abuse suffered by the patient was not
specified in the majority of cases.
In addition, it would be beneficial to investigate different psychological treatment options for this population.
The literature suggests that the most effective treatment
to date is a form of speech therapy focusing on patient
education, comprehension of mental control over breathing using biofeedback, and stress reduction.2,4,7 Further,
psychotherapy, including cognitive-behavioral therapy
and personal construct therapy, has been shown to be
effective for the treatment of PVFD.2,4,7 In considering
PVFD as a conversion reaction, it would be helpful to
investigate treatment options that have been shown to be
effective for somatoform disorders. For example, behavioral treatment, relaxation techniques, and hypnosis have
been found to be helpful in treating somatoform disorders,
specifically conversion disorders and pain disorders.15 It
Laryngoscope 118: April 2008
746
may be that the proper combination of speech therapy
(done by a speech pathologist) and psychotherapy (done by
a mental health professional) will be the most effective
treatment for PVFD.
CONCLUSIONS
This is the first study to investigate PVFD using
psychometrically-sound psychological instruments. Results of MMPI-2 assessment for both adult men and
women show that on average, PVFD is associated with
conversion disorder (P ⬍ .01). However, there also appears
to be a subset of PVFD that is not associated with any
psychopathology. By MMPI-2 criteria, PVFD is not associated with a mood disorder, namely depression or anxiety. However, PVFD patients with a psychological history
are found to demonstrate more depressive and anxious
symptomatology than PVFD patients without a history of
psychological disorder. In addition, PVFD patients with a
history of asthma or GERD are found to have higher
hypochondriasis scores than other PVFD patients. This
suggests that patients with a more extensive medical history are more likely to complain about physical symptoms.
PVFD patients do not have higher levels of stress than the
general population, but they may not cope with their
stress effectively. In fact, male PVFD patients have lower
overall levels of stress, while female patients have more
negative stress and less positive stress.
PVFD is more common among women (81%) and is
common among older individuals (60% age 50 or older).
Patients visited the emergency room for PVFD symptoms an average of 2.4 times in the previous 12 months.
GERD, asthma, and other psychological conditions are
common comorbidities. In addition, a history of abuse is
very common among these patients (38%). PVFD is
often misdiagnosed as asthma but certainly may coexist
with asthma. A combination of history, awake laryngoscopy, pulmonary function tests, and response to various
treatments can help sort this out. The most effective
treatment for PVFD to date has been a form of speech
therapy that includes biofeedback, teaching mental control over breathing, and stress reduction. With the
knowledge that PVFD is associated with conversion
disorder, adding more formal psychotherapy to the
treatment regimen may prove to be important for these
patients.
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